Most women go through pregnancy without significant changes in their mental health. Some women, however, enter pregnancy with a history of pre-existing mental illness, and may already be on medication. A few women develop mental illness for the first time during or following pregnancy.
Mental disorders are sometimes prone to worsen during this period. This is due to a combination of genetic, biological, and environmental factors.
Many patients with pregnancy-related mental illness have a family history of such disorders. In addition, the large fluctuations in hormones that occur during this period contribute to significant mood changes which may predispose to mental disorders in susceptible women. Finally, the presence of several risk factors can result in postnatal mental disorders. These include:
- lack of support from the partner, family, and society
- marital difficulties
- pregnancy-related complications
Postpartum psychosis is the gravest form of pregnancy-related mental illness. It is rare, occurring in only 0.1-0.2% of pregnant women, but it carries a high risk of complications for both mother and infant, and requires emergency hospitalization. It can be successfully treated, however, and is usually quick to resolve, though relapses may occur in some women.
Postpartum psychosis usually occurs within the first month after childbirth, and most commonly within the first few days. However, some cases have been reported to occur much later, up to one year after delivery.
Its symptoms occur suddenly, and include:
- Hallucinations, usually auditory but sometimes visual as well
- Delusions or false fixed beliefs, which may be paranoid (suspicious), grandiose, or bizarre
- Mood swings from mania to depression
- Uncharacteristically uninhibited behavior
- Little sleep
- Severely confused thinking
- Restlessness or agitation
- Disturbed and abnormal behavior compared to normal for the patient
Evaluation and Management
Postpartum psychosis is usually preceded by milder mental illnesses, such as depression. However, women with such symptoms may not admit to themselves or to others that they are experiencing severe inability to enjoy life with the baby. This may be due to feelings of guilt, shame, denial, or fear. They may feel that ‘good’ mothers do not ever feel tired of their babies, or resent the amount of care they need. They may falsely assume that if they share their problems they will be judged as incapable mothers and their babies will be taken away from them. This is why routine well-baby visits should include an evaluation of the mother’s mental health, both before and after delivery. Women with such symptoms deserve care, reassurance, and support in their efforts to care for their families, rather than rejection and blame.
The woman who shows symptoms of postpartum psychosis may do herself or her infant bodily harm. During this time, 5% of these women commit suicide successfully, while 4% kill their babies. Many more have homicidal ideas (which are rarely carried out), but psychotic confusion may lead to poor baby care practices and neglect, which endanger the infant. For all these reasons, the baby must be separated from her until the psychosis is brought under control with appropriate and intensive treatment. Any physician confronted with postpartum psychosis must rule out organic causes.
During visits by patients with postpartum depression, it is extremely essential to follow through on any suicidal suggestions or ideas that life is not worthwhile. This becomes especially urgent if the woman has a plan, access to the tools to carry it out, and a history of attempted suicide. In such cases, the health team must make sure that the patient receives emergency care, because her life is at great risk.
Treatment consists of medication under careful monitoring, with proper education of the patient’s family as to the course of the illness. Medications may include lithium, anticonvulsant drugs like sodium valproate, and the atypical antipsychotic drugs like olanzapine and risperidone. All these pass into breastmilk, and hence the decision to breastfeed may require the cessation of therapy in some cases, and careful supervision by a psychiatrist and neonatal pediatrician in all cases.
Psychotherapy must be begun while the patient is still hospitalized but has regained some degree of oriented thinking. A detailed follow-up plan must be initiated before the patient is discharged, including increased support for the mother during routine housework and baby care, removal of obvious stressors, and access to skilled psychological follow-up.
Postpartum psychosis usually has a remission rate of 50-86%, depending on the underlying disorder (bipolar disorder or schizophrenia). A later onset (after 1 month of delivery) shows a worse prognosis than early onset postpartum psychosis. Patients with high risk of recurrence include:
- Those with a personal or family history of the condition
- History of bipolar disorder
- Those who stop treatment for mania
Pregnant women should be screened for the possibility of postpartum psychosis if they have had:
- Any serious mental disorder including severe anxiety, major depression. schizophrenia or bipolar disorder
- A history of mental health treatment
- Postpartum mental illness in a previous pregnancy
- Eating disorders
Women with a positive history should have sessions with their healthcare providers to decide on their care and treatment during and after pregnancy. This will reduce the high risk of developing postpartum psychosis.
Reviewed by Afsaneh Khetrapal, BSc (Hons)